Promoting client safety in the acute care setting reduces the length and cost of treatment, the frequency

of treatment-related accidents, the potential for lawsuits, and the number of workrelated injuries to personnel. Factors that contribute to the risk of falls include: Being in an unfamiliar environment Difficulty communicating because of impaired vision, hearing, or speech Impaired cognition

Assess the client's motor, sensory, balance, and cognitive status, including ability to follow directions and cooperate. Physiologic alterations increase the client's physical risk factors for falls. Assess the client's medical history and medications. Antihypertensives and diuretics may cause hypotension. Opioids and/or antihistamines may cause drowsiness. Assess the environment for potential threats to the client's safety (e.g., poor lighting, cluttered pathways, wet floors). This reveals the client's environmental risk factors for falls. Observe the client ambulating to determine the degree of assistance needed. This promotes client independence and determines whether the client needs assistance to ambulate.

Equipment used for the prevention of falls includes the following:

Risk assessment tool for falls Hospital bed with side rails Call light/intercom system Wheelchair (for transportation of clients too unsteady or weak to walk) Wedge cushion (to protect client from sliding out of chair) Gait belt (if needed) or other assistive equipment (e.g., cane, walker) Electronic bed and/or chair alarm (if needed) Visual or auditory stimuli (e.g., calendar, clock, radio, television, pictures) (if needed) Diversionary activities (e.g., puzzle, game, music, stuffed animal, dummy tube) (if needed)

Expected outcomes focus on preventing client injury and promoting appropriate use of safety equipment.

The client does not fall or suffer injury while in the health care agency. The client and the family demonstrate the use of the call light to obtain assistance. The client and the family state reasons why safety devices are used.

Use the following evaluation measures:

Determine the client's response to safety modifications and that falls or injuries have not occurred. Observe the appropriate use of the call light to obtain assistance. Ask the client and family to explain the reasons for safety devices. Review the incidence of behaviors that increase the risk for injury without the use of restraints. Verify the absence of violence toward others.

Unexpected Outcomes

The client is unable Reinforce identified risks with the to identify safety client or involve a family member/friend and review the risks. safety measures needed to prevent a fall.

The client starts to fall while ambulating with a caregiver.

Put both arms around the client's waist or grasp the gait belt. Stand with feet apart to provide a broad base of support. Extend one leg and let the client slide against it to the floor. Bend the knees to lower the body as the client slides to the floor.

The client suffers a fall despite all measures taken.

Call for assistance. Assess the client for injury. Stay with the client until assistance arrives to help lift the client to the bed or to a wheelchair. Notify the physician. Note pertinent events related to the fall and

resultant treatment in the medical record. Follow the institution's incident reporting policy. Reassess the client and environment to determine if the fall could have been prevented. Reinforce the identified risks with the client, and review the safety measures needed to prevent a fall.

The client displays behaviors that substantially increase the risk for injury to the client or others.

Intensify supervision of the client and notify the physician. Review the episodes for a pattern (e.g., activity, time of day) that indicates alternatives that could eliminate the behavior. Engage in creative thinking with all caregivers and support service personnel for alternative interventions that promote safe,

Evaluation of assisting client to move up in bed when the client is unable to assist: Inspect the skin overlying pressure areas for erythema (redness) and blanching. Observe it again in 60 minutes. Ask the client if the position is comfortable. Observe the client's body alignment and position. Evaluation for minimizing orthostatic hypotension:

Observe the client for signs of weakness, dizziness, and pallor. Obtain blood pressure, pulse, and respirations if the client experiences weakness or dizziness at any point and on completion of physical activity. Normally blood pressure, pulse, and

respirations increase slightly in response to exercise and return to baseline within 5 minutes of resting. Evaluation of transfer:

Observe the client's ability to bear weight (or avoid bearing weight if prescribed), ability to pivot, and number of personnel needed. Ask the client to describe the level of strength and control. Monitor the length of time the client sits in the chair and the ability to shift weight every 15 minutes. Ask the client to describe his or her response to environmental and positional changes.

Unexpected Outcome for Assisting Client to Move Up in Bed By Using a Lift/Draw Sheet The client develops areas of abnormal reactive hyperemia, blistering, or skin irritation.

Intervention

Change the client's position more frequently. Obtain assistance for the next transfer or positioning. Avoid prolonged pressure on any one pressure area. Readjust the position according to the client's comfort level. Readjust supportive pillows to maintain alignment. Reinforce the rationale for position changes. Provide diversion activities in various positions. Readjust the client's position. Underlying respiratory and/or cardiac diseases may limit the client's tolerance of certain positions. Return the client to the supine position. If the client faints, lower the client to the floor

The client complains of discomfort from stretching because of altered alignment.

The client turns back to the same position frequently and expresses discomfort with alternate positions.

The client complains of respiratory distress.

The client becomes light-headed and dizzy when upright.

safely.

Take the blood pressure immediately. After 3 to 5 minutes, attempt the same procedure. If unsuccessful, wait 1 to 2 hours before attempting it again.

The client does not follow the directions for transfer.

Identify the interfering factors (e.g., anxiety) and provide positive reinforcement for effort and achievement. Demonstrate the procedure for the client in a step-bystep manner.

The client's weakness of lower extremities makes active transfer difficult and/or impossible.

Consider physical therapy consultation. Develop a plan for isotonic or isometric legstrengthening exercises to be done while lying in bed or sitting in a chair. Use a gait belt for balance and support.

The client tends to bear weight on the nonweight-bearing leg.

Have another caregiver support the affected leg as a reminder. Use a gait belt to facilitate balance and control.